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History of Changes from the VAERS Wayback Machine |
VAERS ID: | 918487 |
VAERS Form: | 2 |
Age: | 94.0 |
Sex: | Male |
Location: | Michigan |
Vaccinated: | 2020-01-02 |
Onset: | 2021-01-04 |
Submitted: | 0000-00-00 |
Entered: | 2021-01-04 |
Vaccination / Manufacturer (1 vaccine) | Lot / Dose | Site / Route |
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA | 011L2OA / 1 | RA / IM |
Administered by: Senior Living Purchased by: ??
Symptoms: Cardiac arrest, Death
Life Threatening? No
Birth Defect? No
Died? Yes
Date died:2021-01-04
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Loratadine, Plavix, flomax, Lisinopril, atrovastatin, amlodipine, Pentoxifylline, ASA, Donepezil, trazodone, Metoprolol tartrate.
Current Illness: NSTEMI, Dementia, TIA, COVID-19, HTN, CVA, PVD
Preexisting Conditions: HTN, PVD, Dementia
Allergies: Beta Adrenergic Blockers
Diagnostic Lab Data: None
CDC 'Split Type':
Write-up: Two days post vaccine patient went into cardiac arrest and passed away.
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